ABSTRACT

Context.— Physicians who abuse their patients sexually cause immense harm, and,
therefore, the discipline of physicians who commit any sex-related offenses
is an important public health issue that should be examined.

Objectives.— To determine the frequency and severity of discipline against physicians
who commit sex-related offenses and to describe the characteristics of these
physicians.

Design and Setting.— Analysis of sex-related orders from a national database of disciplinary
orders taken by state medical boards and federal agencies.

Subjects.— A total of 761 physicians disciplined for sex-related offenses from
1981 through 1996.

Main Outcome Measures.— Rate and severity of discipline over time for sex-related offenses and
specialty, age, and board certification status of disciplined physicians.

Results.— The number of physicians disciplined per year for sex-related offenses
increased from 42 in 1989 to 147 in 1996, and the proportion of all disciplinary
orders that were sex related increased from 2.1% in 1989 to 4.4% in 1996 (P<.001 for trend). Discipline for sex-related offenses
was significantly more severe (P<.001) than for
non–sex-related offenses, with 71.9% of sex-related orders involving
revocation, surrender, or suspension of medical license. Of 761 physicians
disciplined, the offenses committed by 567 (75%) involved patients, including
sexual intercourse, rape, sexual molestation, and sexual favors for drugs.
As of March 1997, 216 physicians (39.9%) disciplined for sex-related offenses
between 1981 and 1994 were licensed to practice. Compared with all physicians,
physicians disciplined for sex-related offenses were more likely to practice
in the specialties of psychiatry, child psychiatry, obstetrics and gynecology,
and family and general practice (all P<.001) than
in other specialties and were older than the national physician population,
but were no different in terms of board certification status.

Conclusions.— Discipline against physicians for sex-related offenses is increasing
over time and is relatively severe, although few physicians are disciplined
for sexual offenses each year. In addition, a substantial proportion of physicians
disciplined for these offenses are allowed to either continue to practice
or return to practice.

SEXUAL RELATIONSHIPS between physicians and their patients can have
devastating consequences for the patients1- 6
and can harm physicians' ability to make objective medical judgments.7 Ethical prohibitions against sexual relationships
between physicians and their patients date back at least to the Hippocratic
oath, which was probably written in the late fourth century BC.8
However, only in the last 30 years has sexual contact with patients been clearly
condemned by the medical profession.

In 1973, the first code of ethics of the American Psychiatric Association
(APA) explicitly condemned sexual contact with patients.9
The ethics code published in 1989 added that even with a former patient sex
"almost always is unethical."10 In 1993, the
APA's ethics code stated, presumably based on the growing recognition that
the power imbalance of the physician-patient relationship endured even after
treatment had been terminated, that "sexual activity with a current or former
patient is unethical."11

In 1986, the Council of Ethical and Judicial Affairs of the American
Medical Association (AMA) first issued an opinion7
on physician sexual misconduct that stated, "Sexual misconduct in the practice
of medicine violates the trust the patient reposes in the physician and is
unethical."12 In 1992, the Council updated
this opinion to explicitly define sexual misconduct, stating that all sexual
contact with current patients constitutes sexual misconduct, and "sexual or
romantic relationships with former patients are unethical if the physician
uses or exploits trust, knowledge, emotions, or influence derived from the
previous professional relationship."7

State legislatures have increasingly paid attention to this issue by
passing laws that criminalize sexual contact between patients and psychotherapists.
In 1996, Idaho passed the first law, as far as we are aware, to criminalize
all sexual contact between a patient (except for spouses and domestic partners)
and any medical care provider.13 However, whether
the increased attention to this problem is resulting in increased disciplinary
activity against physicians who have sexual relations with patients is unknown.
In this study, we analyzed the frequency and severity of disciplinary actions
taken against physicians for sex-related offenses and determined the characteristics
of the disciplined physicians.

METHODS

Construction of Database on Disciplinary Activity

In 1989, the Public
Citizen's Health Research Group began requesting
information on all disciplinary orders that state medical boards and federal
agencies (the Department of Health and Human Services, the Drug Enforcement
Agency, and the Food and Drug Administration) had taken against physicians,
including both doctors of medicine (MDs) and doctors of osteopathic medicine
(DOs). By October 1996, 20914 disciplinary orders taken prior to January 1,
1995, had been reported and entered into our database of disciplinary orders.
However, not all jurisdictions have provided complete data for all the years.
Ten states or agencies reported no data or partial data in 1989; 6 agencies
reported no data or partial data in 1990; 4 in 1991; 5 in 1992; and 3 in 1993
and 1994. Some agencies provided data for years prior to 1989, dating back
as far as the mid-1970s.

The information provided by each agency varied, as disciplinary actions
are prepared for public release in different ways by the agencies. Once this
information was received, it was entered into our database in a standardized
format using a detailed data-entry protocol. A record was created for each
order and included the following data items: the agency that sanctioned the
physician, physician name, license number, address, birth date, date of the
disciplinary action, the 2 most serious disciplinary actions, the offense,
and a note field that included any additional relevant information contained
in the information provided by the agency. The agencies varied in the amount
of detail provided, thereby affecting whether the offense or the actions taken
in the disciplinary order could be identified and entered into the database.
For example, the proportion of orders from a given agency that had an identifiable
offense ranged from 11% to 100%, whereas the number of orders with an identifiable
action ranged from 61% to 100%. Overall, 68% of orders had an identifiable
offense, and 95% had an identifiable action.

Actions taken against physicians by state medical boards and federal
agencies were entered as 1 of 24 types. These actions, in order of decreasing
severity, were revocation of license, surrender of license, disallowance of
the right to renew a license, revocation of controlled substance license,
surrender of controlled substance license, disallowance of the right to renew
a controlled substance license, denial of a license, denial of license reinstatement
(from a revocation or surrender), reinstatement (from a revocation or surrender),
suspension, suspension of controlled substance license, emergency suspension,
license probation, probation of controlled substance license, fine, license
restriction, restriction of controlled substance license, reprimand, education,
enrollment into an impaired physician's program or alcohol or other drug treatment
program, cease and desist order, monitoring of a physician's practice, participation
in community service, and exclusion from Medicare (only the Department of
Health and Human Services can take this action). In about one third of the
orders in the database, state medical boards imposed more than 1 action in
a single disciplinary order.

To create a database of disciplinary orders for sex-related offenses,
the database was searched for sex-related orders that had been taken prior
to January 1, 1995. Sex-related orders were defined
as any orders in which the state board or federal agency mentioned a sex offense,
ranging from rape to indecent exposure, as one of the causes for action. Some
sex-related orders may have been missed in this search, as the state board
or federal agency may not have indicated that a sex offense was a cause of
action. Therefore, our database most likely underestimated both the number
of physicians disciplined for sex-related offenses and the number of orders
taken against physicians identified as having been disciplined.

After identifying all relevant orders, the state and federal agencies
that had sanctioned each physician were contacted to determine the current
licensure status of that physician and to inquire about any modifications
(such as court overturns of disciplinary actions) to the selected orders.

In addition to that process, we also updated the database of disciplinary
orders and searched for sex-related orders taken in 1995 and 1996. These orders
were only used in the analyses of the number of orders taken, physicians disciplined
by year, and the type of sexual offense and are not included in the analysis
of severity of discipline or physician characteristics.

Physician Characteristics in the Database on Disciplinary Activity

The date of the earliest action for a sex-related offense taken against
each physician included in the database of sex-related orders was identified,
and the year of this action was used to select an edition of the Directory of Physicians in the United States (titled the American Medical Directory prior to 1992) (for MDs), published by the
AMA, or the Yearbook and Directory of Osteopathic Physicians (for DOs), published by the American Osteopathic Association (AOA).
If the relevant sourcebook had been published in the year of the disciplinary
order, the physician-specific information provided in these publications,
which included information about the physicians' self-reported primary specialty,
board certification status, major professional activity, and ZIP code of the
preferred professional address was obtained. If the relevant publication was
not available from that year, the publication from the closest preceding year
was used.

The birth date of the disciplined physicians was found either on the
original disciplinary information, if the disciplinary agency had provided
it, or from subsequent calls to these agencies. We did not obtain birth dates
for all physicians, as 9 of the 42 state agencies we contacted did not provide
this information.

Whether the preferred professional address of the MDs in the database
of sex-related orders was in a metropolitan area or not was determined by
entering the ZIP codes obtained from the relevant Directory
of Physicians in the United States into the MABLE/GEOCORR Geographic
Correspondence Engine, found on the World Wide Web at http://www.oseda.missouri.edu/plue
/geocorr/.

Frequency and Severity of Discipline and Offenses

The frequency and severity of disciplinary orders for sex-related offenses
was tabulated for the years 1989 to 1994, the period with the most complete
data, and was compared with the overall frequency and severity of disciplinary
orders for all offenses. Additional data on the frequency of sex-related offenses
were included for 1995 to 1996. The number of physicians disciplined in each
year was also determined using a computer protocol supplemented by additional
information in the material from the agencies to identify records belonging
to the same physician.

The severity of orders taken by state medical boards over time from
1989 to 1994 was tabulated, with surrender and revocation of licensure being
the most severe, followed by suspension or emergency suspension, probation
or restriction, and less serious actions. The most serious action taken against
each physician was determined using these same hierarchies. Physicians who
had any orders for which the disciplinary agency had not reported which action(s)
they took were not included in this analysis. Only physicians who had an order
taken after 1988 were included for these analyses.

The offenses for which all physicians, including those disciplined in
1995 and 1996, were disciplined were categorized according to the nature of
the sexual offense. The first 3 categories involve patients and the last involves
persons who are either nonpatients or whose identities were not specified.
The first 3 categories, in descending order of known severity, are (1) sexual
intercourse or sexual relationship or rape involving a patient; (2) sexual
touching or contact; and (3) sexual offenses involving patients, details not
specified. If a physician committed offenses in more than 1 category, he or
she was counted once, and the classification was based on the most severe
identifiable offense.

The percentage of disciplined physicians who were licensed to practice
as of March 1997 was calculated. A physician with all licenses suspended,
revoked, or not renewed was classified as inactive, and a physician who had
1 or more licenses restricted, on probation, or free of restrictions was classified
as active.

The rate of discipline by individual state medical boards was determined
using only the 42 medical boards that had identifiable offenses in at least
50% of all orders reported to us for MDs between 1989 and 1994. For determining
the state with the highest rate of discipline, only the 21 medical boards
that met this criteria and had reported 10 or more sex-related orders to us
between 1989 and 1994 were considered. Only MDs were used in this state-by-state
analysis because we do not have information on disciplinary actions taken
against DOs in states with separate osteopathic boards.

Physician Characteristics

The characteristics of disciplined physicians were compared with the
characteristics of the national physician population, as reported for MDs14 and the DOs.15 Most
of the analysis of characteristics was performed only for MDs, due to difficulty
in standardizing information given by the 2 organizations. However, information
on DOs was included when possible (in the analysis of age and major professional
activity) to present the most complete data possible.

To allow for comparison of our data with the MD data14
in the analysis of the specialties of physicians disciplined for sex-related
offenses, the more than 100 specialties, which a physician can identify in
the Directory of Physicians in the United States,
were grouped into the 38 specialties used by the AMA for statistical purposes.
No data on specialties were collected for physicians whose major professional
activity was listed as unknown or inactive in the relevant Directory of Physicians in the United States. This was necessary to
allow for comparison with the national data14
on physician distribution among specialties. In the analysis of the specialties
of disciplined physicians over time, only the year of the first action taken
against the physician was used.

The age of the physicians at the time of the first disciplinary action
was calculated using the date of the first action and the birth date. In analyses
of the major professional activity of physicians, data on MDs and DOs were
combined. In the analyses of board certification status and practice location,
only specialties that were overrepresented among disciplined physicians and
had large enough cell sizes (greater than 10) were analyzed individually.

Statistical Analysis

Stata statistical software (Stata Corp, College Station, Tex) was used
in the analysis. All tests of proportions were 2-tailed z tests using a significance level of .05. The χ2 tests
for trend that were analyzed with EPI5 software (EPI Information, Inc, Stone
Mountain, Ga) were used in the analysis of time-trend data, with a significance
level of .05.

RESULTS

Frequency and Severity of Discipline and Offenses

The database contained 728 sex-related orders taken against 542 physicians
between 1981 and 1994 and 321 additional orders taken in 1995 and 1996. From
1989 to 1996, the number of physicians disciplined in each year increased
from 42 in 1989 to 147 in 1996, while the number of orders in each year increased
from 47 to 154 (Table 1). The
percentage of all orders reported to us by the state and federal agencies
that were sex related also increased during this time, from 2.1% of all orders
in 1989 to 4.4% of all orders in 1996 (Table 1) (P<.001 for trend). The year
with the highest rate of discipline for sex-related offenses was 1994, in
which 5.2% of all orders were sex related, and 0.02% of all physicians in
the country were disciplined for sex-related offenses (based on 621129 practicing
physicians).16 In 1996, the rate of discipline
for sex-related offenses had declined to 4.4% of all orders.

Table Graphic Jump LocationTable 1.—Number of Disciplinary Orders for Sex-Related Offenses
and Physicians Against Whom They Were Taken, 1989-1994*

Of physicians disciplined for sex-related offenses from 1989 to 1994,
44.4% had one or more of their licenses revoked or surrendered them. For 26.3%,
suspension or emergency suspension was the most serious action; the remaining
29.2% had less serious actions taken against them (Table 2).

Disciplinary orders for sex-related offenses from 1989 to 1994 were
more severe than orders for non–sex-related offenses, with 71.9% of
sex-related orders involving loss or suspension of license, compared with
42.8% of the 11561 non–sex-related disciplinary orders (P<.001). During this period, 38.2% of orders for sex-related offenses
involved loss of license; 33.7% involved suspension of license; 22.3% involved
restriction of license; and 5.8% had no serious actions. There was no trend
toward increased or decreased severity of discipline over time.

Of the 761 physicians disciplined for sexually related offenses, the
offenses of 567 (75%) involved patients. As shown in Table 3, 170 physicians (22% of those disciplined) had sexual intercourse
with their patients, 112 (15%) had sexual contact or touching, and 285 physicians
(37%) committed sexual offenses in which it was not clear which of the previous
2 categories were involved (including sex abuse, sexual assault, sexual encounter,
and sexual favors for drugs) (Table 3).
Offenses of the other 194 physicians (25%) either involved nonpatients or,
in some instances, unspecified individuals.

As of March 1997, 216 of physicians (39.9%) reported as having been
disciplined for sex-related offenses prior to 1995 were licensed to practice
in 1 or more of the jurisdictions that originally sanctioned them. An additional
50 disciplined physicians (9.2%) had no active licenses but had 1 or more
suspended licenses.

The rate of discipline by state boards for sex-related offenses between
1989 and 1994 varied widely, from 3.3 MDs disciplined per 1000 MDs to 0 MDs
disciplined per 1000 MDs. The severity of orders for sex-related offenses
varied from state to state, with the percentage of sex-related orders involving
severe penalties (license revocation, surrender, suspension, emergency suspension,
probation, or restriction), ranging from 68.4% to 100%.

Characteristics of Disciplined Physicians

The specialties of psychiatry, child psychiatry, obstetrics and gynecology,
and family and general practice were all significantly overrepresented among
physicians disciplined for sex-related offenses prior to 1995 as compared
with the proportion of all MDs in the country in that specialty (Table 4). Psychiatry was the specialty
with the highest number (133) of disciplined physicians and was also the most
overrepresented among disciplined physicians. Of all physicians in the country,
6.3% identify psychiatry as their primary specialty, whereas 27.9% of disciplined
physicians were psychiatrists, a 4.4-fold overrepresentation. General surgery,
internal medicine, anesthesiology, and pediatrics were all underrepresented
among disciplined physicians. The percentage of disciplined physicians who
were psychiatrists decreased over time, from 39.4% in 1989 to 21.6% in 1994
(P=.02). In contrast, the percentage of disciplined
physicians who specialized in family and general practice increased from 9.1%
in 1989 to 24.5% in 1994 (P=.02). There were no significant
differences over time for rates of discipline for physicians who practice
obstetrics and gynecology or all other specialties.

Physicians disciplined for sex-related offenses were older than the
national physician population. Among all physicians only 34.5% were between
the ages of 45 and 64 years, whereas 58.1% of disciplined physicians were
in this age group (P<.001) (Table 5). However, among physicians older than 64 years, there was
no significant difference between physicians disciplined for sex-related offenses
and the national physician population.

Table Graphic Jump LocationTable 5.—Age of Physicians Disciplined for Sex-Related Offenses
at the Time of the First Disciplinary Action Taken Against Them*

Disciplined physicians were significantly overrepresented (P<.001) among physicians whose major professional activity was direct
patient care, and significantly underrepresented among those involved in postgraduate
education or non–patient care activities (P<.001
and P=.02, respectively) (Table 6). There was no significant difference between disciplined
MDs and all MDs in the percentage who were board certified overall (58.7%
vs 60.2%) and for each of the specialties studied. Disciplined physicians
as a whole, as well as in each specialty studied, were not more or less likely
to list a preferred professional address in metropolitan areas than all physicians
in the country (86.0% vs 88.4%).

COMMENT

Our study found that the number and rate of disciplinary orders for
sex-related offenses increased over time, from 42 orders (2.1% of all orders)
in 1989 to 147 orders (4.4% of all orders) in 1996, and that disciplinary
actions were more severe for sex-related offenses than for non–sex-related
offenses. However, discipline had not become more severe over time and almost
40% of disciplined physicians were licensed to practice as of March 1997.
Of 761 physicians disciplined, 567 (75%) were disciplined for sexual offenses
involving their own patients (including sexual intercourse, rape, sexual molestation,
and sexual favors for drugs), all of which are gross violations of the boundaries
that must exist between physician and patient.

Disciplined physicians were more likely to practice in psychiatry, child
psychiatry, obstetrics and gynecology, and family and general practice than
nondisciplined physicians and were older than the national physician population,
but were no more or less likely to be board certified than all physicians
in the country. The increased frequency of discipline for sex-related offenses
over time found in our study is in agreement with a report by the Federation
of State Medical Boards,17 which found that
the percentage of actions that involved sexual misconduct had increased from
2.6% in 1990 to 3.9% in 1992.

While this finding suggests that the public is being better protected
from physicians who commit sex-related offenses, our analysis of the severity
of discipline indicates that regulatory agencies may not be adequately sanctioning
those physicians whom they do discipline for these offenses. While the severity
of actions taken for sex-related offenses was greater than that for non–sex-related
offenses according to our analysis, more than 25% of disciplinary orders were
no more severe than probation or restriction of license. The Federation of
State Medical Board's data support our findings, as 28.6% and 31.0% of orders
in their database for 1990 and 1992, respectively, did not involve revocation,
suspension, or surrender of license.17

Physicians disciplined for sex-related offenses apparently are being
allowed to continue to practice with, at most, safeguards, such as having
a chaperone present during examinations and having another physician monitor
patient records. This finding is problematic considering that there are difficulties
in properly assessing the potential for successful and sustained rehabilitation
of these professionals.18,19 Furthermore,
safeguards such as monitoring are often inadequately overseen by medical boards.19

Not only is the severity of discipline for sex-related offenses seemingly
inadequate, but the frequency of discipline, although improving, also seems
to be deficient, as the highest annual rate of discipline in our study was
only 0.02%. Even if all physicians were to practice for 40 years, not even
1% of all physicians in the country would be disciplined for sex-related offenses.
Previous studies indicate that this rate is low in comparison with the actual
occurrence of sex-related offenses. In a 1992 survey of male and female family
practitioners, internists, obstetricians-gynecologists, and surgeons, Gartrell
et al20 found that 9% of physicians reported
having engaged in sexual contact with 1 or more current or former patients.
In 1992, the College of Physicians and Surgeons of British Columbia found
that 3.5% of physicians acknowledged sexual contact with a current patient.21 Comparing these results with our findings suggest
that only a fraction of offending physicians are disciplined.

Certain limitations to our data must be noted when considering the frequency
and severity of discipline against physicians who commit sex-related offenses.
It is probable, due to the difficulty in obtaining detailed information from
disciplinary agencies, that we did not identify all physicians against whom
discipline for sex-related offenses has been taken. This limitation is at
least partly offset by the conservative nature of the estimates in the self-reporting
survey studies. Also, for physicians identified as having been disciplined,
we may not have located all orders taken against them, as some orders for
the same or similar offenses may not have identified the offense as sex related.

Our findings on the characteristics of physicians disciplined for sex-related
offenses are in agreement with previous studies. In a study of the disciplinary
activity of the Oregon Board of Medical Examiners, Enbom and Thomas22 found that the specialties most likely to have reportable
disciplinary actions taken against them were psychiatry and obstetrics and
gynecology. Gartrell et al20 reported that
obstetrics and gynecology and family practice were the 2 specialties in which
physicians were most likely to engage in sexual contact with patients or former
patients, whereas physicians in the specialties of internal medicine and surgery
were less likely to participate in this behavior.

In an earlier survey, Gartrell et al23
had found that psychiatrists reported less sexual contact with patients than
did physicians in any of the specialties reported in the subsequent study,
except internal medicine.20 The discrepancy
between this study and our results may reflect the increased attention to
sex-related offenses in psychiatry and the lack of attention to this problem
in other specialties.

As in our study, Enbom and Thomas22also
found a difference in age between disciplined physicians and their colleagues,
with the odds of sexual misconduct allegation increasing by a factor of 1.44
for each increasing decade of age. This age difference may be due to a lag
time between offenses and discipline or because the rate of sex-related offenses
is higher among older practitioners.

To protect the public, the first line of defense must be the medical
disciplinary system. We recommend that agencies responsible for regulating
physicians be given the authority to protect the identities of survivors of
sex-related offenses by physicians during the investigation and hearing process.
In addition, state medical boards should require all investigators and board
members to receive training in sensitivity to the issues surrounding sex-related
offenses. Although these measures should improve the likelihood that a survivor
of sex-related offenses by a physician will file a complaint, Enbom and Thomas22 data suggest that a low frequency of complaints is
not the only problem. In their study, only 20 (25%) of 80 physicians who had
sexual misconduct complaints filed against them between 1991 and 1995 had
actions taken by the board that were reportable to the National Practitioner
Data Bank. Given that false allegations of sexual offenses by physicians probably
are rare,2,18 this finding implies
that medical boards should take complaints seriously once they are filed.
Moreover, the use of treatment programs and safeguards, such as monitoring
for physicians guilty of sex-related offenses, should be considered with the
knowledge that there are questions regarding their efficacy.

The medical profession, medical education system, and the legal system
also have roles to play in addressing this problem. All state medical boards
should consider enacting laws, such as that passed in Idaho, that criminalize
all sexual contact between any physician and a patient. The medical profession
can participate by altering the pattern of behavior found in past reports
that have suggested that physicians who are aware of sexual misconduct by
their colleagues are unlikely to take any action.5,24

The willingness of physicians to take corrective action against offending
physicians also will be heightened by the existence of medical education that
addresses the issues of boundaries and professional ethics. Gartrell and colleagues20 found that, in 1992, 56% of physicians reported they
had no education during their training regarding physician-patient sexual
contact, and only 3% had taken a continuing medical education course on this
subject. The failure of the educational system to address this issue may allow
new physicians to treat patients with little understanding of the responsibilities
intrinsic to their new position. Finally, patients should be encouraged to
protect themselves by knowing their rights in therapeutic relationships and
by filing complaints with their state medical boards should inappropriate
behavior by a physician occur.

Letters

The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with
the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.

This feature is provided as a courtesy. By using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to the AMA's Terms of Use. The information provided in order to email this article will not be shared, sold, traded, exchanged, or rented. Please refer to The JAMA Network's Privacy Policy for additional information.

Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.